Your Medical Benefits
Medical
Group # 00650877
Your employer has chosen Cigna for your healthcare benefits. The information below provides a high-level summary of your out-of-pocket costs (deductibles, copays and/or coinsurance) as well as your benefits and coverage.
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | OAP HDHPQ Plan - HDHPQ OAPIN Base | Open Access Plus Plan - OAP Base | Open Access Plus Plan - OAP Buy Up | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Individual: $2,500 | Individual: $1,000 |
| Out-Of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 | Not Covered for all benefits | Individual: $7,500 | Individual: $5,000 |
| Family Deductible | ||||
| In-Network | Family Maximum: $10,000 | Family Maximum: $14,000 | Family: $7,500 | Family: $2,000 |
| Out-Of-Network | Family Maximum: $20,000 | Not Covered for all benefits | Family: $22,500 | Family: $10,000 |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual: $9,000 | Individual: $6,000 |
| Out-Of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 | Not Covered for all benefits | Individual: $23,700 | Individual: $10,000 |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $17,000 | Family Maximum: $17,000 | Family: $18,000 | Family: $12,000 |
| Out-Of-Network | Family Maximum: $40,000 | Not Covered for all benefits | Family: $47,400 | Family: $20,000 |
| Primary Care Office Visit | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Emergency Room | ||||
| Plan pays 90% | Plan pays 70% | $500 copay, and plan pays 70% | $750 copay, and plan pays 70% | |
| Urgent Care | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $100 copay, and plan pays 100% | $100 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $200 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 10% Your plan pays 90% | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | ||||
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay 30% up to a maximum of $1,050 | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 |
| Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $2,500 |
| Out-of-Network | Individual: $7,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $1,000 |
| Out-of-Network | Individual: $5,000 |
Family Deductible
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Family Maximum: $10,000 |
| Out-of-Network | Family Maximum: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Family Maximum: $14,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $7,500 |
| Out-of-Network | Family: $22,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $2,000 |
| Out-of-Network | Family: $10,000 |
Individual Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 |
| Out-of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $9,000 |
| Out-of-Network | Individual: $23,700 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
Family Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Family Maximum: $17,000 |
| Out-of-Network | Family Maximum: $40,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Family Maximum: $17,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $18,000 |
| Out-of-Network | Family: $47,400 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
Primary Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| Plan pays 90% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| $500 copay, and plan pays 70% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $750 copay, and plan pays 70% |
Urgent Care
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $200 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 |
| Out-of-Network | Retail: You pay 10% Your plan pays 90% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 |
| Out-of-Network | Home Delivery: Not Covered |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay 30% up to a maximum of $1,050 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 |
| Out-of-Network | Home Delivery: Not Covered |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.
Medical
Group # 00650877
Your employer has chosen Cigna for your healthcare benefits. The information below provides a high-level summary of your out-of-pocket costs (deductibles, copays and/or coinsurance) as well as your benefits and coverage.
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | OAP HDHPQ Plan - HDHPQ OAPIN Base | Open Access Plus Plan - OAP Base | Open Access Plus Plan - OAP Buy Up | |
|---|---|---|---|---|
| Plan Coinsurance | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Individual Deductible | ||||
| In-Network | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 | Individual: $2,500 | Individual: $1,000 |
| Out-Of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 | Not Covered for all benefits | Individual: $7,500 | Individual: $5,000 |
| Family Deductible | ||||
| In-Network | Family Maximum: $10,000 | Family Maximum: $14,000 | Family: $7,500 | Family: $2,000 |
| Out-Of-Network | Family Maximum: $20,000 | Not Covered for all benefits | Family: $22,500 | Family: $10,000 |
| Individual Out-of-Pocket | ||||
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 | Individual: $9,000 | Individual: $6,000 |
| Out-Of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 | Not Covered for all benefits | Individual: $23,700 | Individual: $10,000 |
| Family Out-of-Pocket | ||||
| In-Network | Family Maximum: $17,000 | Family Maximum: $17,000 | Family: $18,000 | Family: $12,000 |
| Out-Of-Network | Family Maximum: $40,000 | Not Covered for all benefits | Family: $47,400 | Family: $20,000 |
| Primary Care Office Visit | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $30 copay, and plan pays 100% | $25 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Specialist Care Office Visit | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Emergency Room | ||||
| Plan pays 90% | Plan pays 70% | $500 copay, and plan pays 70% | $750 copay, and plan pays 70% | |
| Urgent Care | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $100 copay, and plan pays 100% | $100 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Outpatient Radiology | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Independent Laboratory | ||||
| In-Network | Plan pays 90% | Plan pays 70% | Plan pays 70% | Plan pays 70% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Outpatient Physical, Speech, Hearing, and Occupational Therapy | ||||
| In-Network | Plan pays 90% | Plan pays 70% | $60 copay, and plan pays 100% | $50 copay, and plan pays 100% |
| Out-Of-Network | Plan pays 50% | Not Covered for all benefits | Plan pays 50% | Plan pays 50% |
| Pharmacy Formulary | ||||
| Advantage | Advantage | Advantage | Advantage | |
| Retail Pharmacy Customer Share | ||||
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $200 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-Of-Network | Retail: You pay 50% Your plan pays 50% | Retail: You pay 10% Your plan pays 90% | Retail: You pay 50% Your plan pays 50% | Retail: You pay 50% Your plan pays 50% |
| Home Delivery Pharmacy Customer Share | ||||
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay 30% up to a maximum of $1,050 | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 |
| Out-Of-Network | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered | Home Delivery: Not Covered |
Plan Coinsurance
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Individual Deductible
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Individual - Employee Only: $5,000 Individual - within a Family: $5,000 |
| Out-of-Network | Individual - Employee Only: $10,000 Individual - within a Family: $10,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Individual - Employee Only: $7,000 Individual - within a Family: $7,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $2,500 |
| Out-of-Network | Individual: $7,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $1,000 |
| Out-of-Network | Individual: $5,000 |
Family Deductible
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Family Maximum: $10,000 |
| Out-of-Network | Family Maximum: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Family Maximum: $14,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $7,500 |
| Out-of-Network | Family: $22,500 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $2,000 |
| Out-of-Network | Family: $10,000 |
Individual Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 |
| Out-of-Network | Individual - Employee Only: $20,000 Individual - within a Family: $20,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Individual - Employee Only: $8,500 Individual - within a Family: $8,500 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Individual: $9,000 |
| Out-of-Network | Individual: $23,700 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Individual: $6,000 |
| Out-of-Network | Individual: $10,000 |
Family Out-of-Pocket
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Family Maximum: $17,000 |
| Out-of-Network | Family Maximum: $40,000 |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Family Maximum: $17,000 |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Family: $18,000 |
| Out-of-Network | Family: $47,400 |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Family: $12,000 |
| Out-of-Network | Family: $20,000 |
Primary Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $30 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $25 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Specialist Care Office Visit
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Emergency Room
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| Plan pays 90% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| $500 copay, and plan pays 70% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| $750 copay, and plan pays 70% |
Urgent Care
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $100 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Outpatient Radiology
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Independent Laboratory
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Plan pays 70% |
| Out-of-Network | Plan pays 50% |
Outpatient Physical, Speech, Hearing, and Occupational Therapy
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Plan pays 90% |
| Out-of-Network | Plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Plan pays 70% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | $60 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | $50 copay, and plan pays 100% |
| Out-of-Network | Plan pays 50% |
Pharmacy Formulary
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| Advantage |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Base | |
|---|---|
| Advantage |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| Advantage |
Retail Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $75 Preferred Brand: You pay $200 Non-Preferred Brand: You pay $400 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $80 Non-Preferred Brand: You pay $160 Specialty: You pay 30% up to a maximum of $200 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 |
| Out-of-Network | Retail: You pay 10% Your plan pays 90% |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $30 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay 30% up to a maximum of $350 Retail (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Retail (per 30-day supply): Generic: You pay $20 Preferred Brand: You pay $60 Non-Preferred Brand: You pay $100 Specialty: You pay $150 Retail (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 |
| Out-of-Network | Retail: You pay 50% Your plan pays 50% |
Home Delivery Pharmacy Customer Share
| OAP HDHPQ Plan - HDHPQ OAP BuyUp | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 |
| Out-of-Network | Home Delivery: Not Covered |
| OAP HDHPQ Plan - HDHPQ OAPIN Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $240 Non-Preferred Brand: You pay $480 Specialty: You pay 30% up to a maximum of $480 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Base | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $90 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay 30% up to a maximum of $1,050 |
| Out-of-Network | Home Delivery: Not Covered |
| Open Access Plus Plan - OAP Buy Up | |
|---|---|
| In-Network | Home Delivery (per 90-day supply): Generic: You pay $60 Preferred Brand: You pay $180 Non-Preferred Brand: You pay $300 Specialty: You pay $450 |
| Out-of-Network | Home Delivery: Not Covered |
All plans have exclusions and limitations. For a summary of these exclusions and limitations, view the Summary of Benefits and Coverage.